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Patient Education and Counseling 81 (2010) 422428

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Patient Education and Counseling


journal homepage: www.elsevier.com/locate/pateducou

Counselling in infertility: Individual, couple and group interventions


Uschi Van den Broeck a,*, Marysa Emery b, Tewes Wischmann c, Petra Thorn d
a

University Hospital Gasthuisberg, Leuven University Fertility Centre (LUFC), Herestraat 49, B-3000 Leuven, Belgium
Psychosomatic and Psychosocial Medicine SAPPM, Switzerland
c
Heidelberg University Hospital, Institute of Medical Psychology, Germany
d
Practice for Couple and Family Therapy, Germany
b

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 27 February 2010
Received in revised form 1 October 2010
Accepted 6 October 2010

Objective: Infertility is considered a biopsychosocial crisis and infertility counselling is recommended as


an integral part of a multidisciplinary approach. This article will outline the theoretical background and
describe common interventions used in infertility counselling for individuals, couples and in a group
setting.
Methods: This article summarizes the proceedings of the rst campus workshop of the Special interest
group of Psychology and Counselling of the European Society for Human Reproduction and Embryology
(ESHRE).
Results: Infertility counselling offers the opportunity to explore, discover and clarify ways of living more
satisfyingly and resourcefully when fertility impairments have been diagnosed. The Heidelberg Fertility
Consultation Service is presented as a framework for individual and couples counselling and highlights
important issues in counselling patients. For group work a number of steps to set up a group within an
infertility framework are discussed.
Conclusion: In recent years, infertility counselling has become a specialist form of counselling requiring
professional expertise and qualication. Key issues and common interventions are presented to raise
awareness for the specic counselling needs of individuals and couples experiencing infertility and
undergoing medical treatment.
Practice implications: Mental health professionals new to the eld of reproductive technologies as well as
those in other areas of mental health counselling clients with fertility disorders can benet from the
topics addressed.
2010 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Infertility counselling
Interventions
Assisted reproduction

1. Introduction
Infertility is considered a biopsychosocial crisis and infertility
counselling is recommended as an integral part of a multidisciplinary approach. In recent years, infertility counselling has
become a specialist form of counselling requiring professional
expertise and qualication.
2. Methods
This paper summarizes the proceedings of the rst campus
workshop of the Special interest group of Psychology and
Counselling of the European Society for Human Reproduction
and Embryology (ESHRE). The authors outline the signicance and
clarify the different forms of counselling in the domain of infertility

* Corresponding author: Tel.: +32 16 34 28 60; fax: +32 16 34 36 07.


E-mail address: Uschi.vandenbroeck@uzleuven.be (U. Van den Broeck).
0738-3991/$ see front matter 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2010.10.009

and medically assisted procreation. They also describe a theoretical background and suggest possible interventions used in
infertility counselling for individuals, couples and in a group
setting based on their own clinical experience and where available,
in the literature.
3. Results
Pregnancy begins psychologically long before it occurs physically [1]. During pregnancy, a process of attachment to the childto-be-born starts as the couple slowly adjusts to the changing
realities. Individuals progress on the continuum of the imaginary
child (e.g. a child in our minds how we fantasize our future childto-be) towards the real child (e.g. the actual child that is born and
can differ from what we hoped or expected it to be) [2]. This
transition to parenthood, though often a time of happiness and
excitement, can also bring about feelings of ambivalence and a
period of crisis and change. Individuals confronted with impaired
fertility, however, are unable to move on this continuum as the

U. Van den Broeck et al. / Patient Education and Counseling 81 (2010) 422428

crisis of infertility strikes as a transition to non-parenthood [3].


When the wish for a child remains unfullled, the individual is
confronted with boundary ambiguity [1]: psychologically, the
wished-for-child is present whereas physically, the wished-forchild is absent. The question on who is in or out of the family
constitutes a challenge to the couples task of dening their family.
This process can create substantial stress for the individuals involved
[4]. It is often in this process of negotiating the transition to
parenthood or non-parenthood that patients consult a medical
expert in their attempts to full their wish for a child.
Infertility counselling offers the opportunity to explore,
discover and clarify ways of living more satisfyingly and
resourcefully when fertility impairments have been diagnosed
[5]. Counselling in general is a notoriously imprecise term that
covers many layers of meaning depending on the context [5].
Infertility counselling differs from patient-centered care as it
requires professional qualication for addressing the psychological
and social challenges associated with infertility [5]. Of course, the
content of infertility counselling will be different depending on the
setting of the counsellor (within the clinic and medical setting or in
a private practice) and furthermore is dependent on the role of the
counsellor in the setting. Some counsellors are responsible for the
assessment of couples requesting infertility treatment, others
counsel couples on specic issues such as third party reproduction,
adoption, decision making and so on. Patients may be referred by
doctors and other staff, or they may come to the counsellor with
psychotherapeutic questions. The following will outline therapeutic approaches for individual and couple counselling (described
together as many issues are similar) as well as in group work. The
case illustrations were adapted by the authors to illustrate the text.
3.1. Individual counselling and couple counselling
Case illustration
Ellen and Tom, a 38-year-old couple, were never much interested in
having children until the day, 2 years ago, that Tom had a
vasectomy. Though they had made this decision together after
careful consideration of their future together and their wish for a
child, Ellen described feeling that it was the wrong decision,
moments after the procedure had been nalized. They consulted
the fertility centre in distress and wanted to explore if assisted
conception was still a possibility. The fertility team suggested an
ICSI-treatment and though Ellen was relieved to nd out that there
was still an option available to them, she was left confused and
immobilized by fear to make any kind of decision regarding fertility
treatment. After weeks of agonizing, a careful exploration in
infertility counselling of their motives for wanting children, of their
coping resources and communication, the couple nally decided to
go ahead with ICSI-treatment. Ellen described feelings of hope,
sometimes still layered with strong feelings of guilt on the decision
to sterilize her husband while Tom calmly accepted their situation.
After four unsuccessful ICSI-treatments, Ellen asked to speak with
the infertility counsellor of the fertility centre to deal with the
overwhelming feelings of ending treatment and making sense of all
her doubts and efforts to conceive in the last few years.
Furthermore, she wanted help in making decisions about her
future, possibly without children.
3.1.1. A framework for psychosocial exploration
Several publications on individual counselling [e.g. 68] and
couple counselling [e.g. 911] are available to date. A helpful
framework for initial counselling sessions to address the numerous
issues relevant in individual and couple counselling is described in
the Heidelberg Fertility Consultation Service [12]. This psychosocial exploration can highlight certain issues, both individual and

423

in the couple, that can afterwards be explored in further


counselling sessions or psychotherapy if appropriate and desired.
Some of the key questions/themes will be discussed here both from
an individual and couple counselling perspective.
3.1.2. Introducing infertility counselling to patients
In the introduction part of counselling, it is important to establish
open communication with the patients on their ideas, expectations
and scepticism about counselling and the counsellors own position,
in order to dene the objectives of the counselling sessions [13].
Firstly, the counsellor needs to be aware of possible hesitation and
bias of the patient. For many, it is the rst contact with a mental
health professional and they might feel prejudiced or stigmatized on
having to come to see someone about such intimate matters as the
wish for a child and procreation [13]. Depending on how the
counselling session was introduced and communicated by the
medical or paramedical staff, patients may fear evaluation and
rejection or they might perceive themselves to be a failure for
breaking down in front of their doctor [1]. Secondly, the counsellor
should be aware of the added value of infertility counselling for the
patient, the clinic and the counsellor in question [5]. The loyalties and
responsibilities of the counsellor to the clinic or doctors should be
explicit and transparent for the patient in the rst session.
Counsellors will need to discuss with the patients if and what they
will report back to the infertility team as well as patient
condentiality, taking into account the particular position of the
counsellor in the team. For patients, infertility counselling should
provide at the minimum a safe and supportive environment in which
to express and explore their feelings about their infertility experience
and treatment [1]. Thirdly, during the rst counselling session, it is
very rare for infertile patients to be in a position to say exactly what
they expect from the consultation service [12]. Thus, a denition of
infertility counselling at the beginning fulls a number of important
functions. One of them is to act as a corrective to unrealistic
expectations, such as the assumption that removing barriers in the
mind will automatically improve pregnancy prospects [14].
Another function of the introduction part of counselling is to put
the ensuing course of therapy on the right rails from the outset by
establishing a working alliance and dening the roles played by the
participants in it. This can include an open discussion on whether or
not the couple should come into consultation as a couple or if a more
individual approach should be taken [12].
3.1.3. Infertility and the wish for a child
Once a clear working alliance has been established, the
counsellor can invite the patients to talk about the infertility
experience. A careful exploration of the wish for a child that allows
for individual, relational, transgenerational and societal motives
can help provide insight into this overwhelming feeling of
wanting a child [15]. Furthermore, it can sometimes normalize
the experience of being in a crisis and make room for feelings of
hurt, grief, anger, optimism, hope, etc. Various meanings of
wanting children for each of the partners may come to the
surface and give insight into motivations for infertility treatment
as well as boundaries and limits. In addition, when talking about
building a family, inevitably patients will also talk about their
relationship, the couples history and their own family of origin.
Consequently, other important themes and topics may arise, such
as issues of self-acceptance and (gender) identity, coping and
communication, mourning and grieving various losses in life,
alternatives for the child wish and decision making etc. [12].
3.1.4. Subjective versus actual etiology
Another key element that should be discussed in the rst stages
of counselling concerns the subjective etiologies of the infertility
problem, especially for couples with unexplained (idiopathic)

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infertility [16]. This may help to uncover, for example, feelings of


guilt or depressing fantasies such as infertility implying that the
partners are not right for each other, or that one partner is being
punished for wrong doings in the past [12]. In addition, exploring
the perceived etiology is closely related to thoughts and feelings
about stress and infertility as well as self- and body image. If
infertility is diagnosed in one of the partners only, the counsellor
should change attribution errors (externalizing infertility; [17]):
Feeling guilty is not the same as being guilty. It is important to
change internal attribution (Im a failure) to external attribution
(This blow of fate is our challenge). The patients should identify
allocation of blame within the partnership and replace it with
accepting my part of the responsibility for our common problem
[12].
3.1.5. Infertility and dealing with intense emotions
When the wish for a child remains unfullled, many emotional
and physical stresses arise as well as ambivalence [18]. The
conicting emotions that patients are struggling with personally,
interpersonally and socially are often overwhelming and can
exacerbate feelings of helplessness and being out of control. One
way to bring this experience into focus and help patients make
sense of their inner turmoil is to use images or metaphors [1]. A
common metaphor to describe the struggle of infertility treatment
is that assisted reproductive treatment (ART) is experienced as an
emotional rollercoaster or a pattern of rising expectations and
hopes during potential fertile times or treatment followed by
disappointment when a pregnancy does not occur [1]. The visual
image of a rollercoaster also points out the feeling of not being able
to get off while the rollercoaster is in movement, the speed at
which it moves, the feeling of not being in control etc. These issues
and the recurrent emotional crises during ART have to be
anticipated and actively addressed by the counsellor. It is
important to emphasize, that as long as the desire for a child
exists, frustration will exist as well and the emotional rollercoaster
will go on [12]. The patients can limit its amplitudes but cannot
level them out completely [12].
The counsellor can work with patients on strategies of how to
manage the mood swings. Sometimes, practical advice can be given
for particularly difcult situations such as the waiting period before
the blood test to determine a pregnancy. Research has shown that
many patients describe the waiting period as the most distressing
part of medical treatment [19]. Patients are, for example, advised:
1. to seek distraction as often as possible,
2. to indulge in something special during the two weeks after
embryo transfer (e.g. hairdressing, visiting a good friend, going
to the cinema etc.) and
3. to do relaxation exercises (such as hearing a CD with relaxation
exercises, practicing yoga or meditation).
However, the emotional roller coaster of infertility can
overshadow other domains in life which are important or essential
to patients and which they may lose sight of during infertility
treatment [13]. The counsellor can encourage patients to reect on
other goals in life (such as family, spirituality, friendships and
social contacts, work, recreation, community etc.) that can give
meaning or satisfaction. A balance needs to be found between the
goal and value of family building and parenting and other
important life goals as to prevent patients from isolation or
alienating themselves from their life and getting stuck in the
tunnel vision of only infertility.
3.1.6. Infertility and preparing for the road ahead
As most patients tend to be in a passive position during
infertility treatment, taking advice from doctors and paramedical

personnel, it is important to empower them to actively join in the


decisions regarding their infertility problems. This includes
helping to explore possible alternatives to biological parenthood
and boundaries of ART treatment. In this way, a helpful approach is
to stimulate patients to prepare roadmaps and to adjust them
during the course of infertility treatment [20]:
 The aim of the roadmap is to control what can be controlled in
this potentially uncontrollable life crisis.
 Start drawing a satisfaction lifeline from the beginning of the
partnership up to now. Include the ups and downs of e.g. marriage
and couples crises. Outline the grades of life satisfaction as a couple
with and without child in the near and in the remote future.
 Flowcharts including the different options (no pregnancy,
miscarriage, live birth) are central elements of the roadmap.
 Develop Plan B, Plan C etc. from the beginning on.
 Each partner writes his/her roadmap rst, and then the two
roadmaps have to be merged and attuned
 Roadmaps can be rewritten if necessary (e.g. after the rst failed
IVF cycle) but the couple has to set limits to medical treatment.
Ideally this is a joint couple exercise as it will allow similarities
and differences in the partners roadmaps to be brought into focus
in the counselling session directly.
Clinical practice illustrates that many individuals and couples
are reluctant to discuss Plan B at the beginning of medical
treatment. In this case, a careful exploration of the good reasons
not to discuss a Plan B can be considered [13]. The goal in
discussing alternatives is to prevent patients from getting stuck in
the one way tunnel of various treatments and to encourage them
to make alternative scenarios about their life that open up positive
resources and coping strategies.
3.1.7. Infertility and the partner relationship
Infertility does not only impact the couples social and family
network, it can also have a profound (positive and/or negative)
effect on the partner relationship. With infertility and its treatment
come many stressors such as physical complaints of hormone
therapy, emotional distress, changes in sexual life, difcult
decision making, and many of these stressors are experienced
differently by men and women. Research [2123] as well as clinical
practice highlights the importance of couple communication in
infertility. Therefore counselling should improve the couples
communication and aim to strengthen the partner relationship.
Gender differences in infertility are a good way to open up the
discussion on how the patients see themselves and their partner in
regards to the infertility experience [24]. Men tend to benet from
concrete assistance in coping with stress or hands-on advice
about how to deal properly with the crisis their wives/partners
are going through. Women tend to look for emotional support in
overcoming the bouts of depression they experience. The
counsellor should remain neutral towards these differences, and
he/she has to identify the dynamics in the couple relationship and
make them more exible in the discussion with the couple [12].
The following kind of communication pattern typically emerges
in infertile couples: Confronted with the painful experience of
infertility, a woman may want to talk about her pain and sadness,
whereas her partner may feel helpless and withdraw. This circular
pattern can result in polarization and isolation, at a time where
both partners need each other most [12]. While the woman may
perceive her male partner to be more unaffected and much less
depressive than he evaluates his own mood, he may accentuate her
depressive mood nearly as dramatically, in contrast to her selfimage. In couple counselling it can be helpful to visualize this
polarization and to normalize its occurrence. Do men suffer from
infertility? In keeping with masculinity norms, many husbands

U. Van den Broeck et al. / Patient Education and Counseling 81 (2010) 422428

tend to suppress their emotions in an effort both to support their


wives and to conform to social expectations. Withdrawal might be a
way of protecting the woman from her partners pain [25]. This is one
of the major advantages of the couple counselling setting, in that this
assumption can be explored immediately by asking the male partner.
Working on good communication skills can strengthen the
couples connection. Taking time to talk and sharing emotions can
be a big challenge for patients [26]. Sharing emotions implies
addressing some of the pain, the challenges, the uncertainties and
the difcult issues couples are facing. However, avoiding talks
about these core issues because it is painful, to spare the other
partner, or to avoid a long and depressing list of things that go
wrong will not improve couple interaction. When the partners
commit to taking time to share emotions, it is essential that they
listen to each other in an active way. The counsellor can help them
learn to listen without prejudice or assumptions and to pay
attention to verbal and non-verbal cues. For some couples it can
help to take turns in talking and to point out that talking and
listening is not the same as problem solving [26]. The point in
talking and listening is to gain clarity and a new understanding of
how the other partner feels. Finally, using I statements instead of
blaming or guilt inducing communication is essential. I statements relate to a persons observations, affects, views and thoughts
and are essentially about the speaker and not the one who is
listening [26]. For example a woman saying to her husband You
werent there for me during medical treatment, you just dont
care. is likely to evoke a different response in her partner than an
I statement such as I feel really upset, I wanted you there with
me during medical treatment. If couples can learn to communicate with each other and stay close during this intense time of
crisis, their relationship may even grow stronger.
Sexuality and body image are frequently affected by the months
or years of trying to get pregnant [27]. While attempting to get
pregnant spontaneously, a lot of attention is given to sexual
intercourse: it is timed, planned and layered with baby-making
associations. Once a couple starts medical treatment, sexual
intercourse is often left out of the equation and can become
strained. In counselling, the patients can discuss their insecurities
as well as their needs for intimacy. Open and honest communication that takes each of the partners feelings into account is
necessary. For some patients, it can help to differentiate between
Sex for Baby Making in the fertile period of the womans cycle
and Sex for Fun during other times. If the patients develop a
severe sexual dysfunction because of the distress and pressure, this
separation of task-oriented sex and pleasure-oriented sex can be
reinforced and the possible underlying feelings should be
discussed (e.g. body image, guilt, shame, feelings of failure, etc.).
This may even include the use of condoms during the fertile period
for a limited number of menstrual cycles (e.g. two to three cycles)
until the pleasure in sex has returned.
For all of the above issues, the needs and expectations of
patients should be taken into account. An intervention model that
can be helpful in rst session counselling is the PLISSIT model
described by Annon [28]. It is a differential model of treatment,
originally used within sexological counselling, that provides
sensitive and tailored interventions. It builds on the idea that
not everyone needs the same things at the same time. The P
stands for permission these are patients who want permission
from the counsellor to simply talk about their issues. The LI stands
for limited information these patients have specic questions
they want to see answered but nothing more than that. The SS
represents specic suggestions these patients want advice on
how to proceed with certain issues and they want tailored
suggestions. Finally, the IT stands for intensive therapy these
patients represent the smallest group and come to counselling
with psychotherapeutic questions and issues.

425

3.1.8. Infertility and dealing with the social world


When friends and relatives become pregnant spontaneously,
patients are confronted directly with their inability and struggle to
become pregnant. For their social network, life continues and
patients can feel left behind or in limbo with their entire future on
hold. Counsellors can normalize these intense negative emotions
like despair after a negative pregnancy test or envy towards
pregnant women [12]. However, patients are also encouraged not
to run away from these feelings. Avoidance might seem like a good
strategy to deal with the pain of this confrontation but avoiding
these negative emotions and difcult situations (such as baby
showers, maternity wards etc.) will only help for a short term [29].
In the long run, avoidance leads to isolation and lack of familial and
social support, as more social events will become associated with
the patients inability to join with their social network. Partial
disclosure of the fertility problem towards relatives and friends
along with setting clear limits is less energy consuming than
white lies or trying to pretend that everything is ne. While many
of these negative emotions are common, comprehensible and
acceptable, there are also limits that should be considered (e.g.
patients lashing out at their friends with children or making
hurtful remarks to pregnant relatives etc.). Counsellors can help
couples set realistic expectations in dealing with their social
network, and in what they can and cannot expect from their friends
and loved ones [12]. Psycho-education is an important part of this
process and sometimes it is helpful to involve the social network in
this discussion [1].
3.2. Group work
During the clinical practice of infertility counselling, the
development of group work is generally stimulated by requests
from couples or individuals, wishing to meet others in similar
situations. Such educational groups can be oriented towards
sharing experiences, receiving information, improving communication skills, learning relaxation techniques or providing other
forms of psychological support [1,5]. The development of a group
work project requires the evaluation of the specic needs of the
participants, specic skills of the facilitator as well as practical
considerations. In this section, a clinical illustration will precede
the theoretical framework pertaining to group work and will be
followed by a description of practical steps for setting up a group.
Case illustration
Mary is now 34 years of age and she has been trying to achieve a
pregnancy for 4 years. She is keen on natural methods, and now
discovers that her partner presents severe OTA (oligoteratoasthenospermia severe male infertility). Only ICSI (in vitro fertilisation
with intracytoplasmic sperm injection) is possible for the couple to
have a good chance for a pregnancy. Mary is upset and confused,
her partner is feeling useless and guilty. In this situation, couple
counselling allows for both partners to work on acceptance, selfimage, adapting to their circumstances and handling their intimacy
and their entourage. Mary discovered that sharing with friends and
family doesnt always help. Infertility is often not considered a
serious problem. Peoples need to give advice or to make light of
her situation damaged some of her relationships and her selfesteem. Mary described not tting in anymore, not being
understood, becoming sad and pessimistic, putting life on
hold, and hating herself for feelings of jealousy towards pregnant
women. She inquired about encounter groups for people with
fertility problems and two possibilities were offered: the rst was a
support group led by a woman who had successfully had two
healthy children with ICSI treatment, the encounters are organised
sporadically and are free of charge, with no professional leadership.
The second was a therapeutic group led by two psychologists (one

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trained in group psychotherapy and one child psychologist). One


free individual encounter for participant selection was offered, and
then ten sessions of group work for a total fee of 400 Euros. Mary
took part in three non-professionally led sessions, which allowed
her to realise that she was not alone, and that other infertile
couples were dealing with similar reactions and worries as herself.
Clearly, other individuals in a similar context of infertility but
with more inquisitive personalities would consider the therapeutic
group for a more in-depth exploration of their psychological
situation.
3.2.1. A theoretical framework
So, what incites individuals to seek out a group setting in order
to advance in their issues? And which worthwhile objectives have
been identied? Irvin Yalom, in his comprehensive textbook on
The theory and practice of group psychotherapy [30], has
established that group work allows for: the instillation of hope,
universality (Im not alone), imparting information, altruism,
corrective recapitulation of the primary family group, development of socializing techniques, imitative behaviour, interpersonal
learning, group cohesiveness and catharsis (letting it out).
More specically, the different themes encountered in infertility
groups have been examined by Sharon Covington [1]. These themes
are: grief, the loss of control, gender differences, interpersonal
relationships, partnership with the medical team, stress and coping,
decision making, pregnant members, gaining knowledge on social
and legal aspects of other family building options (gamete or
embryo donation, surrogacy, adoption), adapting to pregnancy after
medical treatment, and coming to terms with the possibility of a life
without a children.
Different concepts of therapeutic frameworks are used in order to
dene the interventions and this choice will depend on the group
facilitators their specic skills and training. The group work can be
construed as: cognitive-behavioural, emotive-interactional, psychoeducational (such as in groups with couples considering donor
insemination), staff groups, computer-mediated groups etc. Several
examples for group work in infertility are given in the literature to
date [e.g. 3134]. Different types of groups are being created each
year and with the progression of Internet accessibility, virtual online
groups will probably become more clearly conceptualised as this
means of interaction becomes even more popular [35].
While planning a group intervention, cultural factors represent
an important concern. Very basically, how group work is seen in the
community plays a role in how the recruitment strategy can be set
up, for example by asking for the collaboration of specialised
physicians or advertising in waiting rooms. How the group is named
will be important as well: sharing information concerning
infertility treatments, or relaxation techniques for stressful
procedures may be more enticing (especially for men) than
reections on infertility or relaxing your body, which may
appear too vague and open to interpretation. Furthermore, dening
the number and necessary qualications of the group facilitators, the
facilities, the agenda and nancial issues, all contribute to the time
consuming but creative process of setting up a group [13].
3.2.2. Steps for setting up a group
Setting up a group is dependent on the personal motivations
and resources of the counsellors involved as well as on the patients
or couples requests.
Clinical illustration
At the time that open-identity donors were to be legally
implemented, couples confronted with donor insemination represented a population quite demanding for group work. Their main

request was the sharing of experiences (How do others deal with


this? Do they tell others about the donor? Will they tell their
children? How? When?). A group tailored to couples considering
this family building alternative, with the main goals being
information and exchange of experiences, and using a psychoeducational model was developed. Participation was proposed to
all couples. The group sessions were two hours long, facilitated by
two counsellors (one of whom noted all topics discussed), on a biannual basis, with a maximum 6 couples per session. The
programme included each couple presenting their experiences
and their current situation, followed by an account from a couple
with a child/children or a video showing a family built with the help
of donor insemination. The men and women were then separated in
two groups for 20 min in order to formulate gender-specic
questions, which were then discussed all together. In conclusion, a
series of images were put on the table (a crowd, a clock, a couple on
a path, a building with a lit window etc.) of which each couple could
choose one, representing how they envisaged themselves in their
quest or as a family built by donor insemination. An evaluation
questionnaire was then lled out by each participant.
This illustration aims to point out some creative possibilities in
setting up a group, but also the benet of structure, especially for
evaluation and future development. In conclusion, the following
steps should be envisaged for setting up a group in the eld of
infertility and medically assisted procreation:
 Assess the clinical issues and target population, for example:
infertility in general, open to all couples; donor insemination,
open to couples considering donor insemination; unsuccessful
treatment, for individuals or couples who have stopped ART
treatment; over-40 years of age, for women reecting on issues
related to biological limits; pregnancy after IVF, for women or
couples dealing with the new issues of pregnancy . . .
 Formulate the main goals: information, alleviating stress,
learning a relaxation technique, exchange of experiences,
restoring harmony in the couples relationships . . .
 Dene the technique: cognitive-behavioural, psycho-educational, computer-mediated . . .
 Dene the structure: selection and number of participants and of
group facilitator(s), frequency and number of sessions, time and
place, detailed outline of the sessions (a well-organised session
contributes to the serenity of the facilitators), evaluation by the
participants (very important for all groups, to redene the future
sessions).
Group work is generally very rewarding, as it answers a basic
human need to share a new emotional or a learning process, but
the implementation can be difcult, due mainly to cultural or
social aspects which inhibit initiative in this direction. Remaining
attentive to the expressed needs of individuals and couples is the
rst step in the direction of group work [13].
4. Discussion and conclusion
4.1. Discussion
Infertility counselling is a specialist eld and will continue to
grow in coming years as the impact of infertility and its treatment is
documented more and more in terms of emotional, physical, social
and life consequences. While infertility counsellors help distressed
patients in working through the turbulent emotions associated with
infertility, at the same time they also deal with their own judgement
and possible bias which may impact on how they perceive the
individual or couple before them. Counsellors should therefore
strive to be aware of their own biases and associations and use them
cautiously while allowing the necessary leeway for the individual or

U. Van den Broeck et al. / Patient Education and Counseling 81 (2010) 422428

427

couple before them. A further issue that inuences the infertility


counsellors work is his/her position in relation to the medical
team. Both working as a team member or as an independent
counsellor can have benets and disadvantages [36]. As a medical
team member, the counsellors need to be aware of and should
explicit to clients where their loyalties lie: with the medical team,
the psychosocial unit, or the patient. It is essential to clarify with
patients what information from the counselling session could be
shared with the medical team, or if there is no exchange of
information at all. As an independent counsellor, disadvantages
may lie in the lack of access to the medical le and in-depth
knowledge of how the medical team functions. Advantages lie in
the clear delimitation of medical treatment and psychological
support, which could enhance condence and openness in some
patients. The parties involved will benet from a transparent
approach, with clear boundaries and goals and open communication channels to deal with the ever-changing needs of the patients,
the team and the counsellor.

Conict of interest

4.2. Conclusion

References

Infertility counselling organizations agree that all patients


experiencing impaired fertility should be able to access
individual or couple counselling before, during and after
treatment. There is also international agreement that counselling
should be strongly recommended if third party conception is
considered, if individuals suffer recurrent treatment failure, if
there are ongoing depressive reactions or if they are psychiatrically at risk. Whether psychological support is offered in the form
of individual or couple counselling or as a support group, will
depend on the experience and psychotherapeutic background of
the counsellors and the practical possibilities within a specic
setting. However, some general guidelines can be articulated.
Infertility counselling with individuals offers the opportunity to
explore in greater depth concerns related to the experience and
treatment of infertility such as feelings of sadness, guilt and
anxiety, self-esteem and body-image, coping mechanisms as well
as social implications. Couple counselling offers the opportunity
to explore couple dynamics when faced with infertility, to learn
to support and understand each other, enhance communication
as well as gain insight into gender differences in the experience
of infertility. Group work offers individuals the opportunity to
share with others, in similar situations, the emotional impact of
infertility and to normalize reactions. It also provides the
possibility to learn through the experiences of other couples,
which strategies could be helpful for dealing with specic
feelings and concerns, or for managing relationships with family
and friends.

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4.3. Practice implications


Infertility counselling presents many challenges to the mental
health professionals involved. For the future it seems essential to
invest in building bridges between the different disciplines
involved in the biopsychosocial crisis of infertility. Counsellors
should strive to integrate evidence-based practice into their
clinical work [37] while remaining exible enough to meet the
needs of such a varied population. This article approaches the
issues of communication in a very particular eld of reproductive
health which is notorious for the technological procedures
involved and the related emotional stress. It aims to be of help
to those mental health professionals new to the eld of
reproductive technologies as well as those in other areas of
mental health counselling clients with fertility disorders. Finally, it
can also be insightful for medical and paramedical professionals in
the eld of infertility.

The authors have no conict of interest regarding their work on


this manuscript.
Role of funding
No nancial support was provided for the writing of the
manuscript.
Acknowledgements
The authors would like to thank the ESHRE Special Interest
Group Psychology and Counselling, and the staff and participants
of the Basel Workshop, 29.08.2009 for their encouragement and
support.

428

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